Carotid Endarterectomy in Octogenarians: Mortality, Stroke, and Restenosis
| Available Online: | May, 2024 |
| Page: | 73-77 |
Author for correspondence:
Jovan Petrovic
Department of Cardiology and Internal Medicine, Vascular Surgery Clinic, Institute for Cardiovascular Diseases “Dedinje”, Belgrade, Serbia
E-mail: jovanpetrovic1997@gmail.com
doi: 10.59037/n0j9ec07
ISSN 2732-7175 / 2024 Hellenic Society of Vascular and Endovascular Surgery Published by Rotonda Publications
All rights reserved. https://www.heljves.com
Abstract
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References
Abstract
Carotid endarterectomy (CEA) is a proven surgical intervention for stroke prevention in patients with carotid artery stenosis. However, octogenarians are often considered a “high-risk” group for late stroke prevention, and current guidelines suggest best medical treatment in many cases. This study aims to evaluate whether age ≥80 years is associated with increased morbidity and mortality following CEA.
A retrospective analysis was conducted on 158 consecutive patients (≥80 years) who underwent elective CEA between 2018 and 2023 at a tertiary vascular centre. Patient data, including demographics, clinical presentation, perioperative outcomes, and 6-month follow-up results, were collected. Comparisons were made between octogenarians and a control group of 1,908 patients younger than 80 years. The primary outcome was technical and clinical success, and secondary outcomes included mortality, stroke, and significant restenosis (>50%). Statistical analyses were performed using parametric and nonparametric methods.
No significant differences were found between the groups in terms of sex, functional status, or most risk factors, except for smoking (p<0.001) and atrial fibrillation (p=0.010), which were more prevalent in non-octogenarians and octogenarians, respectively. Perioperative complications (3.8% vs. 4.5%, p=0.699) and in-hospital mortality (0.6% vs. 0.5%, p=0.602) were similar between groups. However, during a 6-month follow-up, octogenarians had a higher rate of cardiac-related mortality (2.0% vs. 0.2%, p=0.012), while stroke rates were comparable (0.6% vs. 1.0%, p=1.000). Restenosis occurred in 7.0% of octogenarians and 8.0% of non-octogenarians (p=0.750).
CEA is a viable option for stroke prevention in carefully selected octogenarian patients, though cardiovascular comorbidities must be closely managed to improve long-term outcomes.
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INTRODUCTION
Carotid endarterectomy (CEA) is an effective surgical intervention for reducing the risk of stroke in patients with symptomatic carotid artery stenosis1. However, the European Society of Vascular Surgery (ESVS) identifies octogenarians as a “high-risk” group, suggesting they may not fully benefit from late stroke prevention, and recommends the best medical treatment alone in most cases2,3. Furthermore, most carotid trials have excluded patients aged ≥80 years2.
While there is limited evidence supporting the best medical treatment alone for this population, a recent meta-analysis suggests that although stroke risk increases with age on medical therapy, selective urgent intervention in symptomatic elderly patients is advisable4,5. Current guidelines suggest that for patients > 75 years with at least one feature that puts them at high risk of stroke on best medical therapy interventional treatment might be helpful3,6.
There is an ongoing debate whether this data remains relevant today because these recommendations are based on the results of large randomized controlled trials that recruited patients between 1983 and 2003 when fewer patients were on statin therapy and more of them smoked7,8. This study aimed to assess whether age ≥80 years is associated with increased morbidity and mortality in patients undergoing CEA.
METHODS
We conducted a retrospective analysis of 158 consecutive patients who underwent elective carotid surgery at a tertiary vascular centre between 2018 and 2023. We obtained data from available medical records. All patients provided informed consent, and the Ethical Committee of the Institution approved this study.
The data included 1) basic demographic data, 2) clinical presentation and course of the disease, 3) preoperative and postoperative therapy, 4) type of procedure, 5) primary outcome classified through technical and clinical success, and 6) mortality and stroke; secondary outcome was defended as significant restenosis (>50%). We analysed outcomes intrahospital and at 6 months (short-term).
Statistical Analysis: We analyzed the data by parametric or nonparametric methods. Observed characteristics were expressed as mean values, standard deviation, median, and interquartile range (IQR). The Mann-Whitney U test was used for continuous nonparametric data, and continuous parametric data were analyzed using Student’s t-test. Categorical data were analyzed using the Chi-square test and Fisher exact test, to determine the statistically significant difference. Significance was set at a 2-sided p<0.05.
RESULTS
| Factor | Octogenarian N=158 | Control N=1908 | p |
|---|---|---|---|
| Male sex, n (%) | 107 (67.7) | 1168 (61.2) | 0.124 |
| BMI, median (IQR) | 25.5 (4.3) | 26.2 (4.8) | 0.138 |
| Functional status – severe dysfunction, n (%) | 1 (0.6) | 9 (0.5) | 0.619 |
| DM, n (%) | 49 (31) | 600 (31.4) | 0.910 |
| CKD, n (%) | 15 (9.5) | 109 (5.7) | 0.055 |
| Smoking, n (%) | 53 (33.5) | 990 (51.9) | 0.000 |
| IHD, n (%) | 19 (12.0) | 269 (14.1) | 0.470 |
| AF, n (%) | 21 (13.3) | 144 (7.5) | 0.010 |
| HTA, n (%) | 145 (91.8) | 1664 (87.2) | 0.095 |
| Previous stroke, n (%) | 40 (25.3) | 405 (21.2) | 0.229 |
Demographic and clinical characteristics of the two groups are presented in Table 1. There was no significant difference between the groups in terms of sex and most risk factors, except for smoking, which was more common in the control group (p<0.001), and atrial fibrillation (AF), which was more prevalent in the octogenarian patients (p=0.010).
On admission, the majority of patients in both groups were asymptomatic (66.5% vs 67.3%, p=0.552). The remaining patients presented with a transient ischemic attack (TIA) (19.6% vs 16%), amaurosis fugax (10.8% vs 13.6%), or stroke (3.2% vs 3.1%). Notably, crescendo TIA was observed in 1.3% of octogenarians and 1% of the control group (p=0.683).
| Complication | Octogenarian N=158 | Control N=1908 | p |
|---|---|---|---|
| Bleeding, n (%) | 3 (1.9) | 31 (1.6) | 0.741 |
| Haematoma, n (%) | 0 (0.0) | 4 (0.2) | 1.000 |
| Thrombosis, n (%) | 1 (0.6) | 4 (0.2) | 0.328 |
| Stroke within 72h, n (%) | 1 (0.6) | 17 (0.9) | 1.000 |
| Death, n (%) | 1 (0.6) | 10 (0.5) | 0.584 |
Key Perioperative Findings:
- No significant difference in cumulative complications (3.8% vs 4.5%; p=0.699)
- Median length of hospital stay similar (4 vs 4 days, p=0.063)
- Average clamping time comparable (18.3 ± 5.6 vs 19.3 ± 11.9 minutes, p=0.418)
- In-hospital mortality: 0.6% vs 0.5% (p=0.602)
6-Month Follow-up Outcomes:
- Cardiac-related mortality: 2.0% (octogenarians) vs 0.2% (control), p=0.012
- Stroke rates: 0.6% vs 1.0%, p=1.000
- Significant restenosis (>50%): 7.0% vs 8.0%, p=0.750
DISCUSSION
The short-term outcomes following CEA between octogenarian and non-octogenarian patients provide critical insights into the procedure’s efficacy and safety across different age groups. The study’s findings reveal that while some differences in outcomes exist, particularly concerning cardiac-related mortality, the overall results suggest that CEA remains a viable intervention in elderly patients.
The demographic and clinical characteristics of the two groups showed several noteworthy patterns. Importantly, there was no significant difference in sex distribution or most risk factors between octogenarians and non-octogenarians. However, smoking was significantly more common in the non-octogenarian group (p<0.001), while AF was more prevalent in the octogenarian group (p=0.010). The higher prevalence of AF in older patients is consistent with the known increase in AF incidence with age and highlights the importance of considering this arrhythmia when planning perioperative management and postoperative monitoring in octogenarians9.
Perioperative complications were similar between octogenarians and non-octogenarians, with no significant difference in cumulative complication rates. The median length of hospital stay and average clamping time were comparable, suggesting that advanced age did not significantly prolong the operative process or recovery. The in-hospital mortality rate was low in both groups, with no significant difference observed.
The 6-month follow-up outcomes highlighted some differences between the groups, particularly in mortality rates. The octogenarian group experienced a higher rate of cardiac-related deaths (2.0% vs 0.2%, p=0.012), suggesting that age-related cardiovascular comorbidities contribute significantly to postoperative mortality in this population. This finding underscores the need for comprehensive cardiovascular evaluation and management in elderly patients undergoing CEA, both preoperatively and during follow-up10.
Interestingly, the stroke rates at 6 months were low and did not differ significantly between the groups (0.6% in octogenarians vs 1.0% in non-octogenarians; p=1.000). This low incidence of stroke across both age groups reinforces the effectiveness of CEA in preventing cerebrovascular events, even in older patients.
CONCLUSION
Carotid endarterectomy is a safe and effective procedure for stroke prevention in octogenarians, with perioperative complication and in-hospital mortality rates comparable to those in younger patients. Although octogenarians demonstrated a higher rate of cardiac-related mortality at 6-month follow-up, the overall stroke and restenosis rates were similar across age groups. These findings suggest that age alone should not preclude CEA in elderly patients and that CEA can be a viable option for selected octogenarians with a life expectancy of more than three years as part of stroke prevention strategies.